Failure to Monitor and Document Weekly Weights Upon Admission
Penalty
Summary
The facility failed to implement and monitor weekly weights upon admission in accordance with professional standards of practice for one resident. The resident was admitted with multiple diagnoses, including a fracture of the left pubis, hypertension, and a history of myocardial infarction, and was cognitively intact at the time of admission. The facility's policy required weights to be taken upon admission, the next day, and then weekly for four weeks, but documentation showed gaps in recorded weights, with missing entries between certain dates and a significant weight gain not being identified or addressed in a timely manner. Interviews with staff, including CNAs, LPNs, the Unit Manager, the Registered Dietitian, and the Nursing Supervisor, revealed that all were aware of the weight monitoring policy and the importance of regular weight checks. However, there was a lack of clarity and follow-through regarding the actual documentation and monitoring of the resident's weights. The staff could not account for the missing weights, and there was no documentation of refusals or reasons for the omissions. The Registered Dietitian and Medical Director were not aware of the significant weight change until it was brought to their attention by the surveyor. A review of the facility's documentation practices showed inconsistencies, with additional weights being added to the record after the surveyor's initial review, based on information from a former employee. The Director of Nursing acknowledged that weights should have been entered promptly and that missing weights were only discovered during the survey process. The facility's policies required accurate and timely documentation of weights and maintenance of accurate medical records, which was not followed in this case.